Module 9: OCD symptomatology and treatment

Question 1

What are obsessions and compulsions in OCD?

Answer 1

Obsessions are recurrent and persistent thoughts, impulses or images that are experienced as intrusive and undesirable, and that cause anxiety or distress. Compulsions are repetitive actions or psychological activities that the person feels compelled to respond to in reaction to an obsession or according to rules that must be rigidly applied. These aim to prevent an event but no real connection with what needs to be neutralized

Question 2

What is phenomenology?

Answer 2

study of experiences, perceptions, thoughts, feelings, memories, and fantasies. The goal is to describe reality as it appears to a person.

Question 3

What are related disorders to OCD?

Answer 3

Hoarding disorder: persistent difficulty of disposing of belongings due to a strong need to save objects + suffering associated with disposing of them
Body dysmorphic disorder: Preoccupation with one or more subjectively perceived defects or imperfections in one’s appearance that are not perceived by others or are considered by them to be insignificant. This is associated with repetitive body-oriented behavior or psychological activity
Trichotillomania: Repeated pulling of the hair despite attempts to stop it.
Skin picking disorder: Repeated plucking of the skin causing skin lesions, despite attempts to stop it.
O-C or related disorder due to substance/medication
O-C or related disorder due to a somatic condition
Otherwise specified O-C or related disorder
The unspecified O-C or related disorder

Question 4

What are the cognitive biases in OCD?

Answer 4

intolerance of uncertainty; thought-action fusion, which means that excessive importance is attached to thoughts; an exaggerated sense of responsibility (both for one’s own thoughts and behavior as for situations that might be risky to others); overestimation of danger; perfectionism.

Question 5

What are some evidence-based treatments used for OCD?

Answer 5

• Exposure response prevention
• SSRIs and dopaminergic medication are prescribed
• Deep Brain Stimulation of basal ganglia to stimulate it, has been found to be successfully used for compulsive patients

Question 6

What is the aim of phenomenology?

Answer 6

Aims to stay ahead of symptoms and free from theoretical assumptions and premises. Being as open-minded as possible is important here. The central issue is the study of essences and the problems with finding definitions of essences. It tries to give a description of experience as it is without referring to psychology or sociology. Husserl phenomenology looks at how the world is constructed and experienced through conscious acts. Always will be provisional, ongoing and in sketching new angles.

Question 7

How can essence be defined?

Answer 7

What it is that makes a thing what it is rather than being something else. It is how we think, how we encounter something and how we are put into question

Question 8

How is obsession related to preoccupation?

Answer 8

Mental act has an intentionality, orientation, direction towards content. Intentionality illustrates the relationship between mental acts and inner/outer contents. The intrusive thought can cause the patient to feel passively subjected to over-ruling nature of the thought. Attention selectively focuses on a topic and the compulsion. Idea of passive obsessionality during obsessions and active obsessionality during compulsions.

Question 9

How does obsessionality affect perspective?

Answer 9

Difficult to take distance from intentional object and the obsessed subject coincides with the object of obsession-> cognitive and affective isolation. Perspective diminishes and frame of normality vanishes and difficult to assess nature of symptoms

Question 10

How does obsessionality risk losing themselves?

Answer 10

There is a desire to be aware of mental acts not to lose themselves, dependence on the conscious act and difficulty to cope with the world which causes more anxiety and self-consciousness. Believe they are responsible for dangers. Also related to resistance which results in more obsessionality and reinforcement and association could be linked to neurobiological mechanisms

Question 11

How does compulsivity manifest?

Answer 11

Through objective compulsivity which is the idea that a mental event leads to another mental event. Also subjective compulsivity which is the feeling of being compelled, which is more specific to OCD. Can become forced as is functional and effective, but can become more drastic due to tolerance and losing effectiveness. If omitted could lead to distress, similar to addiction

Question 11

How does compulsivity differ in obsessions and compulsions?

Answer 11

• in obsession is direct as experienced from beginning
• compulsivity is indirect as it occurs after a lap of time and due to typical process

Question 11

How does compulsivity raise the problem of free will?

Answer 11

Patients feel forced to think something and perform an act, and absence of this links to lack of control which results in fear. Experience an obsession as compulsive and involuntary and resistance against the obsession as free will.

Question 12

Why can’t OCD be diagnosed for those with schizophrenia, addiction and Parkinson’s disease?

Answer 12

Not free in thinking or acting and the compulsivity cannot be diagnosed, OCD differs from repetitive, ritualistic behaviours seen for those with schizophrenia, Parkinsons etc. OCD only involves the subjective compulsivity distinguishes compulsivity from impulsivity-> compulsivity= loss of control while there is control, impulsivity= control when there is no control

Question 13

How does reflection manifest in OCD?

Answer 13

Obsessions and compulsions arouse anxiety, fear and loss of control, guilt, shame or aggression, so always sense of dialogue with disease. Subjective reflection characteristic for OCD and shows in egodystonia and insight.

Question 14

How can OCPD be differentiated from OCD?

Answer 14

OCPD- no obsessions and compulsions but force their will on the world and the others, not seen as disturbing

Question 15

How are obsessions different from delusions?

Answer 15

Patient is with the delusion but patient is against the obsession in OCD. Those with delusions cannot reflect on it and see whether it is egosyntonic nor egodystonic

Question 16

How does insight manifest in OCD?

Answer 16

Rarely occurs at peak of preoccupation and OCD patients not able to distinguish between possibility and reality, also strengthening impact of the rituals. But when the truth confirms their beliefs, they tend to react with disbelief

Question 17

What is the role of certainty in OCD?

Answer 17

OCD symptoms have a lot in common in that they can be narrowed down to problem of certainty and control, aside from heterogeneity. The desire for absolute certainty can be explicit and loss of control through symptoms can create a need for absolute control and absolute security. But not based on objective knowledge or external reality but on feeling.

Question 18

What do obsessions consist of?

Answer 18

• organized into themes like contamination, responsibility for causing or not preventing harm, taboo thoughts about sex, violence, blasphemy and the need for order and symmetry
• experienced as unwanted and uncontrollable in that they invade consciousness
• incongruent with belief system
• obsessions are resisted and need to dealt with, neutralized or avoided

Question 19

What do compulsions consist of?

Answer 19

• reduce or remove obsessional distress can involve decontamination, checking, repeating routine activities, ordering and arranging
• rituals are senseless and excessive and need to be performed repetitively and reduce distress
• can be covert or overt
• reliable and valid OCD symptoms involve both obsessions and compulsions (contamination, responsibility for harm and mistakes, incompleteness and unacceptable taboo thoughts

Question 20

Conditioning model approach to OCD

Answer 20

Fear acquired by classical conditioning and maintained by operant conditioning such as anxiety reduction behaviour and avoidance can be negatively reinforced. Obsessional stimuli found to evoke anxiety. But traumatic conditioning not needed for development of obsessions

Question 21

Cognitive behavioural approaches

Answer 21

Intrusive thoughts are interpreted as threatening, personally significant and provoking uncertainty. Others interpret as being meaningless or harmless. But develops into an obsession if attached to high degree of importance and uncertainty. This evokes distress and motivate the person to engage in compulsive behaviours to gain certainty about negative outcomes, control unwanted thought and prevent harmful consequences. Counterproductive as: escape from anxiety, learning distress can decline naturally and that avoidances leads to more frequency of obsessions. Also preserve dysfunctional beliefs and misinterpretations. But CBT factors do not fully account for OCD symptoms

Question 22

What are specific targets for reducing obsessive-compulsive symptoms?

Answer 22

• correct maladaptive beliefs and appraisals
• decrease avoidance and compulsive behaviours that serve as barriers

Question 23

What does exposure therapy involve?

Answer 23

Confronting fear but safe objects, situations, thoughts, sensations to reduce fear. Can be situational or imaginal or interoceptive exposure to confront body sensations which accompany anxiety and fear. The selection is used depending on the individual’s fears

Question 24

Which theories explain the effectiveness of exposure therapy?

Answer 24

Habituation and emotional processing theory which is that a feared stimulus during exposure activates a fear structure which results in the development of a non-fear structure. Inhibitory learning explains better as fear associations remain intact but there is a new learning about the feared stimulus having a safety-based meaning rather than fear-based meaning. Exposure therapy can develop new non-threat associations and enhance accessibility of new associations in different contexts and over time

Question 25

Response prevention

Answer 25

Resisting urges to perform compulsive behaviours. Those who received only exposure therapy was more effective than those who only received response prevention. But was superior to exposure in reducing washing compulsions-> response prevention more beneficial for reducing compulsions while exposure better for reducing obsessional fear. ERP more effective than comparison treatment, but not effective for everyone

Question 26

What do cognitive techniques involve?

Answer 26

Cognitive restructuring involves rational and evidence-based challenging and correction of dysfunctional thoughts and beliefs. Techniques involved: didactic presentation of educational material, Socratic dialogue, cognitive restructuring techniques. Behavioral experiments may also be used but a discussion of mistaken cognitions is necessary for their effectiveness.

Question 27

What is involved with ACT?

Answer 27

Psychological flexibility is associated with higher stress reduction. Acceptance interventions complement the enhancement of inhibitory learning and help foster willingness to experience obsessional thoughts and uncertainty coming from them. Importance of : willingness to experience obsessional distress, recognizing thoughts and feelings as neutral, using treatment to move towards own values

Question 28

What is involved with the initial phase of treatment?

Answer 28

one should gather information and do a functional assessment of the following:
→ external stimuli triggering obsessive thoughts
→ content of the thoughts
→ feared consequences of the exposure to stimuli
-> avoidance patterns and compulsive behaviours
Done using questionnaires and self-monitoring

Question 29

What happens in planning and education?

Answer 29

The client is given the cognitive model of OCD and given an explanation for the various treatment techniques to be used. Lists are made for exposure items (fear hierarchy) and compulsive behaviors to be targeted. Significant others can be invited.

Question 30

What happens after agreement on treatment plan?

Answer 30

Exposure response prevention is done, under supervision then as homework and first exposing to most feared stimuli and to other contexts for generalization. Cognitive techniques and ACT metaphors for intense distress. Relapse prevention plan at end of treatment to list concrete techniques for dealing with distress and normalizing return of fear

Question 31

Obstacles to successful treatment

Answer 31

• fear of long-term or unknowable consequences
• disgust and not just right experiences
• family accommodation

Question 32

Fears of long-term of unknowable consequences

Answer 32

Trying to disprove beliefs can be futile and reframing the problem as an intolerance of uncertainty useful, which should be identified through instances in daily life. Can consolidate by asking for summaries of discoveries and surprises

Question 33

Disgust and not- just-right experiences

Answer 33

Paying attention to expectancies and how they are violated could also be useful when the emotion of disgust is related to the obsession. Disgust has been found to be more resistant to habituation than fear or anxiety. Expectancy tracking can similarly be used in cases where things seem out of order or not just right.

Question 34

Family accommodation

Answer 34

Interpersonal suffering in client’s surroundings and has been linked to more severe OCD symptoms, worse treatment outcome. Reduces motivation of client to engage and to overcome should identify and understand accommodation, effective communication and problem-solving to reduce behaviours. One function of accommodation may be that it is the primary way a partner shows care, concern, and love. Additional behaviors for doing this can be identified instead of accommodation.

Question 35

When can accommodation occur?

Answer 35

→ a significant other participates in the compulsive behavior of the client
→ a significant other helps in avoidance strategiesone
→ significant others help with resolving or minimizing problems resulting from obsessions